Author Note:Linda
Horan, Discipline of Occupational Therapy, School of Health Sciences,
National University of Ireland, Galway, Ireland; Jackie Fox, Lecturer,
Discipline of Occupational Therapy, School of Health Sciences, National
University of Ireland, Galway, Ireland.

Linda Horan is now at the Department of Occupational Therapy, Naas General Hospital, Naas, Co. Kildare, Ireland. Correspondence
concerning this article should be addressed to Linda Horan, Department
of Occupational Therapy, Naas General Hospital, Naas, Co. Kildare,
Ireland. Email: Linda.Horan@hse.ie

Abstract

Objective: This
study explored the experience of individuals with mental health
difficulties who completed the Wellness Recovery Action Plan (W.R.A.P.)
intervention. Participant perspectives on the therapeutic elements of
the WRAP, its role in recovery and constructive feedback are presented.Methods:
Using descriptive phenomenological methods, in-depth semi-structured
interviews were conducted with four individuals with mental health
difficulties who attended a WRAP programme in a community mental health
centre in Ireland.Results:
Overall, participants felt that completing the WRAP was a therapeutic
group experience. The identification of early warning signs and crisis
planning proved particularly valuable by individuals who felt more
empowered to actively manage their own mental health. Qualitative
perspectives from this study point to the importance of introducing the
WRAP early in an individual’s recovery journey, and providing multiple opportunities to repeat and review the process.Conclusions and Implications
for Practice: Results support the findings of earlier studies in which
the WRAP was found to be a self-management programme that contributes
to the recovery of individuals with mental health difficulties. Group
peer support was valued by participants, but future research should
study the effectiveness of the WRAP in comparison to other peer support
programmes.

In
recent years, the traditional notion that the lives of individuals with
mental health difficulties’ comprise only of unavoidable decline has
been rejected (Bellack, 2006). There is now a widespread understanding
that it is possible to reclaim or recover a meaningful life in spite of
such difficulties (Jacobson, 2003). There are various definitions of
recovery in existence within the literature. Definitions include
recovery as an outcome, as a process and as a personal journey
(Strauss, 1996; Sheehan, 2002). The existence of such disparate
definitions strengthens the stance by Jacobsen (2001, p.15) that “the
meaning of recovery will vary, depending on who is asking and
interpreting, in what context, to what audience, and for what purpose”.
Therefore, it is reasonable to infer that the single over-arching
feature of recovery is the fact that it is individualised.

Despite
the individualised nature of recovery for individuals with mental
health difficulties, the fundamental principles upon which the concept
is based remain the same. It is upon these principles that mental
health services around the world are beginning to base their approach
to mental health care (International Mental Health Commission, 2005).
Principles such as an individual’s right to control their own life and
manage their own mental health and the importance of shared
decision-making between service user and provider, form the basis of a
recovery-orientated approach to care (Wallcraft, 2005; Davidson et al.,
2009).

The underlying philosophy of a
recovery-orientated approach is similar to that of another approach to
mental health care, the self-management perspective. Both are of the
view that individuals are active agents and the focus is to empower
them with a view to enhancing their self-efficacy (Lorig & Holman,
2003; Davidson et al., 2009). Self-management programmes involve the
provision of information by either professionals or peers (Mueser et
al., 2002) and were designed to provide people with the knowledge,
skills and supports to self-direct their care (Onken et al., 2007). A
variety of self-management programmes have been developed in recent
times but the most widely distributed of these is the Wellness Recovery
Action Plan (W.R.A.P.) (Slade, 2009).

The W.R.A.P
was developed in the United States, in 1997, by a user of mental health
services, Mary Ellen Copeland, and further developed by participants in
an eight-day recovery skills seminar for psychiatric symptoms
(Copeland, 2008). It is now offered in a variety of countries including
Ireland (Mental Health Commission, 2005; Cook et al., 2011). It is
underpinned by a number of recovery principles including personal
responsibility, education, hope, self-advocacy, peer-support and future
planning (Copeland, 2008). The idea is to allow individuals to develop
an individualised recovery plan in a personal folder, comprising a
variety of self-help strategies to improve their ability to take
responsibility for their own wellness and manage their symptoms
(Copeland 1997, 2004). In practice, individuals may be facilitated to
develop their individualised recovery plan in a one-to-one relationship
with their therapist, or with a peer facilitator. Conversely, mental
health services often design a series of groups with the purpose of
facilitating individuals to develop their recovery plan with the
support of peers. The number of group sessions may vary, but will be
focused on specific components of the WRAP; making a daily maintenance
plan, learning strategies to identify and respond to triggers, learning
strategies to identify and respond to early warning signs, recognising
a crisis and making a post-crisis plan (Copeland, 2004). In the Irish
context where this study took place, individuals are assisted by an
occupational therapist and a nurse both of whom are certified WRAP
facilitators to create a WRAP folder and recovery plan through six
sessions on a weekly basis. Usually, the WRAP is facilitated as a group
intervention however in cases in which the therapist felt it was more
beneficial for the client, it is facilitated on an individual basis.

Literature ReviewA
paucity of research has investigated individuals with mental health
difficulties use of the WRAP. This small body of research has been
predominantly quantitative and has focused primarily on measurement of
an individual’s recovery using a pre-established construct of recovery.
The outcome measures used are based on the assertion in the wider
literature on recovery that service users often conceptualise common
elements of recovery such as hopefulness, acceptance, empowerment and
support.

For instance, Starnino et al., (2010) used The
Recovery Markers Questionnaire (RMQ) (Ridgeway & Press, 2004) to
measure various recovery-related outcomes in their quasi-experimental
study. Findings suggested that following the WRAP, there was a
significant increase in recovery orientation as indicated by an
improvement in mean scores across outcomes such as process factors,
goal-oriented thinking, self-agency, self-efficacy, symptoms, social
support and basic resources. The RMQ was also used by Fukui et al.,
(2011), but conflicting results were reported as there were no
statistically significant group intervention effects for the treatment
group following participation in the WRAP. The use of an outcome
measure that has not yet been tested for psychometric validity presents
itself as a weakness of these studies. The study by Starnino et
al., (2010) also lacked a control group and comprised a small sample
size (n=30), further weakening the strength of these findings.
Contrastingly, Fukui et al., (2011) made use of a control group. In
addition, two-stage least squares regression analysis deduced that
selection bias typically associated with a non-equivalent group design
was not a problem in this case. A comparison of these studies suggests
that the participants who attended the WRAP programme achieved the same
level of recovery than those who did not as measured on the RMQ.

Cook
et al., (2009) utilised The Recovery Assessment Scale (RAS) (Giffort et
al., 1995) which comprises five recovery subscales including Personal
Confidence and Hope, Willingness to ask for Help, Goal and Success
Orientation, Reliance on Others, Not Dominated by Symptoms. There were
significant increases observed in the scores for overall recovery
following participation in a WRAP programme, and on each of the five
subscales, thereby indicating improvement. In the randomised control
trials (RCT) by Cook et al., (2012), and Cook et al., (2013), there
were similar results found using the RAS. Cook et al., (2012) compared
the WRAP with services as usual. The total RAS score and some of the
RAS subscales indicated that participants in the treatment group showed
significantly greater improvement over time in comparison to
participants in the control group. Cook et al., (2013) compared the
WRAP with a nutrition education programme and the results suggested
that participants in both the intervention and control group improved
significantly over time.

The study by Cook et
al., (2009) lacked a control group but Cook et al., (2012) and Cook et
al., (2013) carried out two single blind randomised control trials. The
multisite nature of these studies, data collection at multiple points
in time large sample sizes and the use of a valid and reliable outcome
measure adds further weight to the findings of these studies.
Therefore, there is strong evidence to suggest that WRAP improves
recovery outcomes. WRAP improves recovery outcomes more than the usual
care provided, but just as much as a nutrition education programme.
This leads to the inference that perhaps it is not specifically the
content of the WRAP that causes it to be effective, but the support
provided by a group intervention.

A summary measure of the BSI, the
Global Symptom Severity Index (GSI) was used to provide an overall
measure of an individual’s level of psychological distress in the study
by Cook et al., (2013). Participants in both the intervention and
control group improved significantly over time.

Similar
results were found on the Modified Colorado Symptom Index (Conrad et
al., 2001) which was used by both Fukui et al., (2011) and Starnino et
al., (2010). This measure has showed excellence for several types of
validity, test-retest reliability and dimensionality. Starnino et al.,
(2010) on the other hand, reported conflicting results with findings
suggesting no decrease in psychiatric symptoms. However, due to the
small sample size (n=30) of this study, it may have been difficult to
find significant relationships from the data, as statistical tests
normally require a larger sample size to ensure a representative
distribution of the population (Macnee & McCabe, 2008).

Therefore,
there is evidence to suggest that the WRAP improves psychiatric
symptoms. However, Cook et al., (2013) found that there was an
improvement in the intervention group following the WRAP and the
control group following a nutrition education course. Again, this could
suggest that it is the group support element that results in
improvements, rather than the content of the WRAP programme.

Service Utilisation and NeedService
utilisation is considered a recovery outcome in some of the literature
with a view that a reduction in the use of services is a measure of an
improvement in one’s mental health. Cook et al., (2013) assessed the
impact of the WRAP on the use of and need for mental health services
over time compared with a nutrition and wellness education programme.
The Support Service Index or SSI (Heller, Roccoforte & Cook, 1997)
was used to measure service utilisation and need. Results indicated
that compared with people in the control group, WRAP participants
reported a significantly greater reduction over time in service
utilisation. Participants also reported a significantly greater
decrease over time in the total number of services needed.

The
use of telephone interviews may have made it difficult for interviewers
in this study to establish their genuineness in seeking sensitive
information. Nevertheless, data was collected at multiple points in
time and from multiple sites, a single blind RCT design was employed
and complete allocation concealment up to the point of assignment was
achieved, all of which suggests that this study provides evidence that
the WRAP has a sustained effect on both reported mental health service
utilisation and self-perceived need for services.

Client SatisfactionClient
satisfaction is an important and commonly used indicator for measuring
the quality in health care. Health professionals may benefit from
satisfaction surveys that identify potential areas for service
improvement through patient-guided planning and evaluation. Client
satisfaction with the WRAP was extremely high in the study by Cook et
al., (2010) as indicated by the open-ended comments participants left
on their evaluation questionnaires. Themes derived from thematic
analysis of responses included a view of wellness as attainable and
on-going, the influence of and growth of support networks, the
increased ability to recognise and successfully manage stressors and
symptoms and pride in new knowledge and skills.

Client
satisfaction with the WRAP was also investigated by Wilson et al.,
(2013). This descriptive cross-sectional survey consisted of
quantitative and open-ended narrative or qualitative questions.
Participants completed the Mental Health Statistics Improvement Program
for which data on reliability is reported (Howard et al., 2003).
Factors correlating to client satisfaction with the WRAP included
autonomy and services. Length of programme participation was a factor
which correlated with client satisfaction with clients who attended the
WRAP programme for a longer period of time being more satisfied.
Findings also suggested a belief that exposure to the WRAP at a younger
age would provide a better opportunity for recovery, a belief that
sharing one’s story is constructive, there is a need for support and
that it is crucial to accept that recovery does not happen overnight.

Cook
et al., (2010) used content analysis which is unobtrusive and
nonreactive (Lee, 2000). However, few details about the methods of
qualitative data collection were provided and so the credibility of the
findings is reduced. Wilson et al., (2013) however, used an instrument
that is widely used in public mental health systems and has been
identified by consumers as addressing important concerns. Furthermore,
the use of narration in this study enabled a deeper understanding of
participants’ perspectives in addition to the quantitative findings.

In
conclusion, the sparse amount of research pertaining to the WRAP as an
intervention in psychosocial rehabilitation nevertheless provides
evidence for a number of outcomes. There is evidence to suggest that
WRAP contributes to an individual’s recovery outcomes. Evidence also
suggests that the WRAP reduces psychiatric symptoms as well as service
utilisation and need. However, some research gaps exist. The
quantitative methodologies used in the studies on the WRAP comprised of
pre-established constructs of recovery. Therefore, they could fail to
accurately capture the individualised nature of recovery. Similarly,
individual perspectives on the relationship between the WRAP and
psychiatric symptoms and service utilisation and need have not been
captured. Client satisfaction with the WRAP was found to strongly
correlate to autonomy, services and length of program participation
however client perspectives on the different aspects of the programme
itself remain unknown. Client perspectives on ways to improve the WRAP
have yet to be explored, and the perspective of Irish mental health
service users is unknown on this topic.

Aim This
research aimed to capture an in-depth understanding of the value of the
WRAP as an intervention in psychosocial rehabilitation from the
perspective of individuals who have participated in a WRAP programme.
Its primary objective was to explore individual’s experience of the
WRAP. Its secondary objectives were to elicit the role of the WRAP in
individuals’ recovery, their perceptions of the therapeutic elements of
the WRAP and their use of the WRAP after the programme ended.

MethodologyAccording
to O’Leary (2004), phenomenology is the study of phenomena as they
present themselves in direct experiences. The primary focus of
phenomenological work is the meaning of lived experience, from the
first-person point of view (Husserl, 1970). A descriptive
phenomenological approach was used to capture client perspectives on
the value of the WRAP as an intervention within mental healthcare. By
obtaining this insider view, insight was gained into what the
experience of using the WRAP is like. The researcher was required to
interact directly with the participants to gather their description of
their lived experiences. The researcher also took steps to bracket her
ideas, preconceptions and personal knowledge of the WRAP before
interviews were conducted through the use of a personal reflection
(Drew, 1999). There are features to any lived experience that are
common to all persons who have the experience referred to as universal
essences or eidetic structures (Natanson, 1973). For the description of
the lived experience to be considered a science, the researcher must
have identified commonalities in the experience of the participants, so
that a generalized description is possible. In this way, a universal
description of the phenomenon, the WRAP, was provided by the lived
experience of the participants (Tymieniecka, 2003).Recruitment Procedure There
was one main recruitment method; a list of all the adults that
participated in the previous three WRAP programmes at the participating
community mental health centre was compiled by the gatekeeper of the
study. The gatekeeper was an occupational therapist who had facilitated
the group. An information leaflet was sent to all of the individuals on
the list. The leaflet outlined the nature, purpose, duration, possible
effects and risks of the study. Interested individuals were invited to
contact the researcher (first author) directly. A date and time to
conduct the interviews was arranged with individuals who met the
inclusion criteria.

ParticipantsA
purposeful homogenous sample was used whereby individuals who had
participated in a WRAP programme were purposefully sought out and
recruited from the participating community mental health centre. Four
participants self-identified to take part. One participant was female
and three were male. Their ages ranged from 35 to 61 years old. Each of
the participants had different mental health concerns; depression and
anxiety (Participant A), psychotic hallucinations (Participant B),
schizophrenia (Participant C) and social anxiety disorder and
depression (Participant D). The number of times participants had
participated in a WRAP programme varied; once (Participants A and C)
twice (Participant B) and three times (Participant D). The time lapse
since participants completed a WRAP programme varied from 6 months to 2
years. 3 participants completed WRAP in a group format while one
participant completed it on an individual basis. Procedure The
semi-structured interviews were conducted in the participating
community mental health centre over a three week period. An interview
schedule was developed by the researcher based on a literature review,
the research aims of the study, and had input from an experienced
occupational therapy researcher. The schedule covered the following
areas; individuals’ view of the WRAP, individuals’ view of the WRAP in
relation to recovery, the therapeutic elements of the WRAP that
contributed to recovery and the elements of the WRAP individuals have
continued to use since their participation in the WRAP programme. The
direction of the interview was lead mainly by what was said by
participants however the researcher ensured all the questions were
asked and a similar wording was used across all interviews. Each
interview was recorded using a password-protected Dictaphone and lasted
between twenty and forty minutes. The interviews were transcribed
verbatim. All relevant data protection measures were adhered to. Ethical ConsiderationsFull
ethical approval was sought and received from the Health Service
Executive Research Ethics Committee for the region in January 2015. All
participants were provided with an information leaflet including the
details of the aims and procedures of the research and the
participants’ right to withdraw at any time without any negative
consequences for their future receipt of services. Written consent was
obtained from each of the participants. Due to the rich narrative
description typically elicited from participants in this study design,
infringements of confidentiality by means of deductive disclosure were
of particular concern to the researcher. In order to retain such
valuable description and protect the identity of participants the names
of participants were replaced with pseudonyms and any other identifying
information was removed.

A number of safeguards
were in place to reduce any potential distress which might have been
caused by the probing nature of the study design. Interviews were
conducted in the community mental health centre participants attended
regularly and arranged at a time when staff members were available on
site. The gatekeeper of the study who was the occupational therapist
who facilitated the WRAP programmes was present during the interview.
Consequently, this enabled data collection to be conducted within a
familiar environment, in the presence of an already established
relationship.

AnalysisThematic
analysis was used to analyse the data as it is a method involving the
identification, analysis and reporting of patterns in data, which are
important to the description of a phenomenon (Aronson, 1994).
Specifically, Attride-Stiring’s (2001) six step process was used.
First, the data was reduced into manageable and meaningful sections by
using a coding framework. Once all the text had been coded, themes were
derived. The identified themes were organised into thematic networks.
The contents of each network were described and the description
supported with text segments. The underlying patterns that appeared
were explored and noted. The main themes and the patterns
characterizing these themes were summarised. The original research
questions were re-examined and the patterns that emerged in the
exploration of the text were used to address them.

ResultsFour
themes were identified; the meaning of recovery, the role of the WRAP
in recovery, the therapeutic elements of the WRAP, and feedback on the
experience of being a WRAP participant.

The Meaning of RecoveryParticipants’
conceptualisations of recovery illustrated the different meanings it
had for each of them. For Participant A, recovery meant “looking
forward to things and having an appetite for life”. It also meant an
improvement in the feelings and symptoms he experiences because of his
diagnosis, such as “a little bit more confidence and patience and
interest and better concentration”. In contrast, Participant C felt
that recovery means a peaceful time, “quietness and rest”. One
participant denoted that recovery means being aware of deterioration in
their mental health and having the ability to take action to prevent
further decline. For them, recovery was “this thing of being aware when
things are slipping and … to be able to put things in place to stop it
escalating” (Participant D).

There was a
distinctively different view on recovery expressed by one participant.
He described recovery as non-existent. He asserted that recovery is not
possible and that there are only mechanisms to help one cope with
mental illness. He stated firmly that, “There isn’t any [recovery].
There is (sic) ways of dealing with it. It’s like an addiction, there’s
no cure, there’s just prevention” (Participant B).

The Role of the WRAP in RecoveryDespite
the different perspectives held by participants on the meaning of
recovery, all participants felt the WRAP contributed to an improvement
in their mental health. WRAP played a role in individual’s recovery in
a number of ways including the reduction of psychiatric symptoms and
the prevention of hospitalisation.

One participant
experienced a reduction in psychiatric symptoms, which she accredits to
the WRAP. She stated that, “a year or two ago if I got depressed it
could last months, now it probably wouldn’t even last weeks. I’m able
to work with the WRAP and get myself out of it” (Participant D). Linked
to this, for two participants, using the WRAP directly affects whether
they need hospital admission or not. Participant B said that if he
doesn’t use the WRAP, “it means the difference between hospital or at
home”. Specifically, WRAP helps them to “recognise the early warning
signals and get help. It stops you from getting so bad that you’re
hospitalised” (Participant C).

The participants were
able to describe clear examples of occasions in which the WRAP played a
role in the prevention of hospitalisation. Participant B said that,
“the week before last, if I didn’t put some of the WRAP into action
here with the nurses, I would have been back in hospital”. This was
similar to Participant C’s experience; “last October I started to get a
bit unwell and I got in touch with the nurse straight away you know,
and the WRAP kind of helped me do that. I got my medication increased
and I was grand”. Therapeutic Elements of the WRAPParticipants
noted two main beneficial elements of the WRAP. Firstly, participants
described the content covered in the WRAP as beneficial, particularly
the education on the various tools to incorporate into ones recovery
plan. Secondly, participants described the positive impact of the
format in which the WRAP programme was facilitated.During
the creation of a WRAP, participants learned about the value of a daily
maintenance plan. The daily plan allowed them to identify “certain
things that you can do” (Participant A) and “organise yourself an awful
lot better” (Participant B). Participant B also found learning about
the personal bill of rights very beneficial, and this knowledge led to
him being more self-assured in exercising his rights, as he stated,
“You have the right to feel unwell and I didn’t think I had that right.
... Now I know I’ve the right to say no and I’ve been practicing that
and if it’s a problem it’s not mine, that’s the WRAP for you”.

Learning
how to recognise triggers and warning signs of becoming unwell is an
important part of the WRAP, and two participants identified that this
content was particularly beneficial. Participant B felt that
identifying triggers “plays a big role because I didn’t even know what
me (sic) triggers were or what signs to look out for”. Participant C
said that “the main thing I got out of the WRAP was recognising the
early warning signs of getting unwell so I can get help quick. One of
the early warning signs for me is I get all me (sic) possessions and I
throw them out in the bin”.

This increase in self
knowledge led three participants to comment that the WRAP enables them
to put a plan in place when becoming unwell. Participant C recognised
the importance of “learning the early warning signs and acting upon it
before it got too late. WRAP made me feel more secure that if I was
getting unwell that I’d get help quicker rather than let it go too far
until I was hospitalised”. Participant B was able to give specific
detail of his warning signs and what he would do if he noticed them;
“if I’m feeling dirty and I don’t wash or I’m feeling hungry and I
don’t eat I’ll go to my WRAP and have a look and think well this is
something now that has to be dealt with”. In addition, Participant D
noted the importance of being able to “pinpoint who would take over if
there was a crisis”.

Participants felt there were
certain benefits associated with the facilitation of the WRAP in a
group format despite the fact one of the participants had in fact
participated in a WRAP programme on an individual basis. For
Participant D, it was actually a new social experience; “I never sat in
a group until I did the WRAP the first time”.

Three
of the participants commented that an environment comprising
individuals with similar experiences fostered a comforting atmosphere
and a sense that one was not alone in having a mental illness.
Specifically, Participant A stated that “when there are other people
that you can familiarise with, I feel more comfortable”. This was
similar to Participant D, who felt that the other group participants
were “there for the same reason so you feel very comfortable and very
safe”. This led to a reduction in the sense of isolation for one
participant; “They could say something and you could think I’m not the
only one in the world that has this way of mind and thoughts”
(Participant B).

One of the participants completed
the WRAP programme on an individual basis but he also felt that a group
would facilitate a feeling of not being the only person with mental
illness. He felt that the sharing of ideas within a group would provide
access to otherwise unknown information; “You’d learn that not having a
wash or a bath in two weeks was one of their early warning signs and
would say, that happens to me too whereas if they didn’t say it you
mightn’t think of it” (Participant C.)

One
participant described how hearing individuals’ personal accounts of
recovery evoked the idea that their own was possible. She described how
“you hear other people and how bad they were and how it is possible to
recover and think to yourself well, you know, I could get better”
(Participant D.)

Two participants emphasized
the supportiveness of the group, and the respect and understanding
shown between all involved. It was “a really good group who stuck
together” (Participant B) and there was “respect, everybody understands
each other” (Participant D). There was also a sense that the group
built some lasting relationships. Participant D felt that the group
members are “still friends”, and described meeting group members
socially for coffee or to go to the cinema. She felt that the social
benefits of the group continued after the formal intervention was
completed; “afterwards when it’s finished there’s support”.The Overall Experience and Suggested Improvements to the WRAPParticipants
described their overall experience of the WRAP. In doing so, a number
of potentials ways to improve the WRAP were identified. The overall
experience of the WRAP was referred to with it being described by some
as a pleasant experience; “I enjoyed it” (Participant A) and others as
a mediocre experience; “doing it was alright” (Participant C).

The
content of the WRAP was referred to by participants in both a positive
and a negative way. There were indications that there was a lot of
information to take in, and that this meant that individuals needed to
revise and re-read their workbooks. While Participant A indicated it
“was all positive stuff”, he also mentioned that “I just didn’t abide
by it much at all really. It went out of my head”. Participant B felt
that “there’s too much for one time” but also that he has “used it a
few times since I’ve come out (of hospital)”. He indicated that he
continues to look at his workbook; “I still read it. It’s nice to
remind myself every so often”. In contrast, Participant C stated that
he has “lost the information now”.

Participants
shared their perspectives of the individuals to whom they would
recommend the use of the WRAP, the people the WRAP is suitable for, the
ways in which the WRAP could be improved and the future of one’s
personal WRAP. These are all important to consider within the context
of the facilitation of WRAP programme in the future.

Participants
A, B and C declared that they “would recommend” the WRAP to other
individuals with mental health difficulties, and Participant B noted
“if they want something that’s really helpful to them, I’d recommend
them doing it”. Two participants noted that the WRAP is suitable
“regardless of how well or unwell someone was” (Participant A) and that
“you can use it anytime” (Participant C). One participant noted that
the WRAP is useful even “if you never had a mental illness”
(Participant D).

Directly or indirectly, the
participants described possible ways of improving the WRAP. Two
participants felt that it was necessary to complete the WRAP a number
of times because different things are learned each time. Participant B
stated that; “there is always something in it that’ll pop up and it
mightn’t have been something that popped up either of the other times”.
Similarly, Participant D felt that doing the WRAP more than once was
important because “it was the second WRAP in particular I became more
aware of things that affect me. It took me that long for things to just
click”.

Two participants felt that WRAP would be more
beneficial if it was introduced into one’s life earlier. Participant B
indicated that it could have played a role in preventing ill-health;
“if I knew then what I know now, through WRAP, it may not have got out
of hand as much as it did”. So, as Participant D mentioned, “it was a
pity that WRAP didn’t come around an awful lot sooner”.DiscussionResults
of this study highlight the individualised nature of recovery, the role
of the WRAP in recovery, the therapeutic elements of the group and the
ways in which the WRAP could be improved.

The Meaning of RecoveryConflicting
views were expressed among participants regarding belief in the concept
of recovery. One participant noted that recovery means an improvement
in the feelings and symptoms he experiences because of his mental
health condition. Reduction of psychiatric symptoms is a commonly
identified outcome in much of the recovery literature (Bond &
Campbell, 2008; Lloyd et al., 2008). For another participant recovery
means a quiet and peaceful time. Similarly, in a previous personal
narrative, the quiet life was identified as indicative of recovery
(Rudnick, 2012). To a different participant, recovery means awareness
that one’s mental health is deteriorating and having the ability to put
a plan into action to prevent further deterioration. This perception of
recovery strongly correlates to section two of the WRAP entitled early
warning signs. This section comprises the identification of the signs
that may indicate if a situation is beginning to worsen and the
development of a plan of how to respond to these signs (Copeland,
2001). Therefore, it is reasonable to surmise that the philosophy of
the WRAP is embedded within the meaning this participant attributes to
recovery.

Previous research comprising personal
narratives of mental illness support the range of meanings associated
with recovery by participants. For instance, Stocks (1995) denotes
recovery as living a worthy and healthy life despite disability while
Caras (1999) describes it as trusting that the bad times will
pass. The participant in this study who expressed non-belief in
recovery compared mental illness to an addiction, in that there is no
cure. The term ‘recovery’ is often mistakenly understood to be
synonymous with the word ‘cure’ (Davidson et al., 2006). Unlike studies
conducted on the WRAP to date, this study obtained participants’
perspectives on the meaning of recovery.

Consequently, this
enabled the intricacy and profundity of recovery to be captured
(Belleck & Drapalski, 2012). Participants’ views of recovery
further illustrated the individualised nature of recovery. In doing so,
the argument that recovery defies simplistic measurement is further
substantiated (Anthony, 1993).The Role of WRAP in Recovery The
WRAP in its entirety was found by participants to foster recovery in
three ways; alleviating symptoms, preventing hospitalisation and
reducing service utilisation. This supports the findings of previous
research on the WRAP. Cook et al., (2009) reported a statistically
significant decrease in global symptom severity one month post WRAP
while Cook et al., (2012) reported a significantly greater reduction in
the symptoms of depression and anxiety in participants following
participation in the WRAP in comparison to the control group who
received services as usual. In addition, service utilisation including
admittance to hospital was reduced among WRAP participants in the study
by Cook et al., (2013) when compared to participants in a nutrition
education programme.

The above-described improvements
in mental health are all regarded as aspects of recovery for
individuals with mental health difficulties (Torrey et al., 2005;
Mueser et al., 2006; Bond & Campbell, 2008).Hence, the findings of
this study add support to previous findings demonstrating that WRAP can
contribute to the recovery of individuals with mental health
difficulties. This study however adds to the literature by reporting
first-person accounts of the role of certain therapeutic elements of
the WRAP in recovery. Thereby, the study has contributed new insights
into the potential elements of the WRAP that may make it effective.
Future research is warranted to further substantiate these findings.

Therapeutic Elements of the WRAPParticipants
indicated that there were certain elements of the WRAP that fostered
improvements; the content of the WRAP and the group format. The
section of the WRAP on recognising triggers was described as one of the
most beneficial elements of the WRAP with most of the participants
describing its usefulness. Participants noted that it created an
awareness of triggers, which has similarly been noted in previous
research on the WRAP carried out by Cook et al., (2010). According to
participants, an awareness of their triggers improved their mental
health by underscoring the importance of daily measures to sustain
wellness. In addition, participants attributed the prevention of
relapse to this section of the WRAP. The section on early warning signs
was also identified by participants to have contributed to the
prevention of relapse. This is consistent with previous findings
related to the use of early warning signs which suggests that positive
outcomes were experienced including the prevention of relapse (Novacek
& Raskin, 1998; Pitschel-Walz et al., 2001).

Other
content covered appeared to empower participants. Empowerment has
previously been identified as an important factor in recovery
(Campbell, 1997; Cohen, 2005). Firstly, the personal bill of rights
provided participants with information regarding their human rights.
Subsequently, one participant began to exercise his rights and felt
self-assured in his decision to do so. The crisis planning element of
the WRAP also proved empowering as it facilitated a participant to
formulate plans for who would take over if there was a crisis. Thereby,
it can be construed that participants referred to empowerment as an
outcome (by the outcomes of decisions) and as a process (being an
active participant in the decision-making process), a previously noted
viewpoint in the literature (Mc Lean, 1995; Salzer, 1997).

There
were also certain benefits associated with the facilitation of WRAP in
a group format. Previous research supports the stipulation that there
are specific therapeutic benefits of group-work; cohesiveness,
universality, instilling hope, interpersonal learning and imparting of
information (Yalom, 1995). In this study, participants felt that the
group fostered a comforting atmosphere and a sense that one was not
alone in the experience of mental illness. This shared experience led
to the removal of a sense of isolation (Yalom, 1995). Hearing group
members’ personal accounts of recovery evoked in participants a sense
that recovery is possible, demonstrating the role of WRAP in instilling
hope. An emphasis was placed by participants on the supportiveness of
the group, and friendships had emanated from it (Yalom, 1995). This
finding is consistent with previous research on the WRAP in which
participants noted a growth in their support networks following the
WRAP (Cook et al., 2010).

As aforementioned,
self-management programmes tend to be delivered by either a peer or a
professional facilitator (Mueser et al., 2002). A recent study suggests
that there are different benefits associated with each of these types
of facilitators (Pallaveshi et al., 2014). For example, Cook et al.,
(2010) elucidated that peer facilitators were especially powerful in
instilling hope. Some authors contend that there are more benefits
associated with a peer facilitator than with a professional facilitator
such as an occupational therapist, a nurse or a counsellor (Foster et
al., 2008; Druss et al., 2010). Despite this fact, previous research on
the WRAP has failed to determine the impact of a peer-facilitator or
professional facilitator on the outcomes of programmes. In this study,
the participants valued the support of their peers, but also the
professional support of a facilitator. Therefore, perhaps, it is a
possibility that professional-led WRAP programmes are just as
beneficial as peer-led programmes once facilitated in a group format.
Future research is warranted to explore this possibility.

Overall Experience and ImprovementsParticipants
found the WRAP programme enjoyable as an overall experience. However,
there were a number of ways suggested to improve the WRAP. Some
participants felt that there was too much information provided, and one
had forgotten much of the material. Taking into account the personal
journey of recovery, perhaps the WRAP needs to be completed more than
once and for sessions to be more frequent. There may also be benefits
to introducing WRAP to individuals much earlier on in their recovery
journey. This small scale study provides initial insights from
participants in an Irish context into what could be considered with
regards to the WRAP programme. Further research could examine how the
WRAP could be used as a mental health promotion intervention before
individuals reach a crisis. There may also be benefits in examining how
individuals may repeat the WRAP at different stages of their lives or
at different points in their recovery journey.

LimitationsThere
are a number of limitations pertaining to this study. Participants had
varying degrees of the experience being studied as some had
participated in the WRAP programme more than once. Individuals can
self-refer to the WRAP group and so repeating it may be a sign that
they enjoyed it, or that they had forgotten it and wanted to revise or
they may have been referred by someone else on the multidisciplinary
team. The reason for some of the participants participating in the
programme more than once is unknown.Participants were
required to self-identify to take part in the study. Thereby, there may
be an element of bias secondary to the client’s willingness to
participate. Participants may have had a particular viewpoint of the
WRAP they wished to convey (Olsen, 2008). This may have resulted in
participants under or over exaggerating perspectives pertaining to the
WRAP. In addition, the presence of the gatekeeper during the interviews
may have caused participants to feel obliged to speak of the WRAP in a
positive manner, as the gatekeeper was the occupational therapist who
facilitated some of the WRAP programmes attended by participants.
However, this was a condition of the ethical approval for the research.

This
study has a small number of participants, similar to many exploratory
qualitative studies. However, the researcher included description of
how the study was conducted, making it possible to apply the findings
of the study to another similar context, group or setting (Mc Daniel
& Bach, 1996). A physical audit trail comprising the
stages of the research study, from the identification of the research
problem to the key research methodology decisions was kept by the
researcher. In this way, the research process was clearly documented in
a logical and observable manner (Kock, 2006). Failure to reach data
saturation is also identified by some authors as a limitation (Francis
et al., 2010). To counteract this limitation however, thick description
was utilised when presenting the results of the study; conveying the
complexities and richness of the experience of using the WRAP
(Silverman, 1997).

Implications for Future Research and Practice An
understanding of recovery as a personal process is increasingly
underpinning the policy of the Irish mental health system (Department
of Health & Children, 2006). This study contributes to raising
awareness of the individualised nature of recovery and the
misconception that all individuals believe in the concept of recovery.This
study supports the earlier findings of the WRAP as a self-management
programme which contributes to the recovery of individuals with mental
health difficulties (Cook et al., 2012). It confirms and complements
results from outcome studies with regard to the significant effects of
the WRAP on recovery outcomes (Cook et al., 2009; Cook et al., 2010),
psychiatric symptoms (Cook et al., 2009; Cook et al., 2010; Doughty et
al., 2008; Fukui et al., 2011) and reduced use and need for services
(Cook et al., 2013). Hence, this study adds to and supports the
existing body of knowledge. It is a further indication that WRAP should
be offered as part of standard treatment for service users with mental
health difficulties.

This study provided some
insights into the therapeutic elements of the WRAP that may contribute
to its effectiveness, particularly the identification of personal
triggers and early warning signs. This should encourage mental health
professionals to explore these concepts with those they work
with. The study contributes to literature about the therapeutic
benefits of group-work, but future research should seek to examine
whether peer-led or professional-led groups are more effective. Since
the participants in this study found that the WRAP helped them to
reduce their symptoms and avoid hospitalisation, it indicates that the
WRAP could lead to cost-efficiencies for mental health services, but
this warrants future investigation.

References

Anthony, W. A.
(1993). Recovery from mental illness: The guiding vision of the mentalhealth service system in the 1990s.
Psychosocial Rehabilitation Journal, 16 (4), 11–23.